Would adding a new trauma center save lives on the South Side?

Research suggests longer ambulance rides may not affect survival.

October 13, 2011

The South Chicago neighborhood is a long way from a Level I trauma center. Adult trauma patients who get seriously injured in this ZIP code are in for a long ambulance ride: 22 minutes on average, more than three times the average run time for ZIP codes further up Chicago’s lakeshore. At least 15 times over three years, ambulances leaving this ZIP code took at least 40 minutes – twice the citywide standard. We’re often told that every minute counts in the race to get medical care for someone who’s been shot or pulled from a car wreck. That raises the question of whether people in South Chicago, or a number of other Southeast Side neighborhoods, are less likely to survive their injuries.

That turns out to be a complicated question that people have been asking in Chicago since the late 1980s, when the University of Chicago Hospitals and Michael Reese Hospital pulled out of Chicago’s trauma network. That left no trauma center on the city’s South Side. The people who designed the system adjusted it to serve that part of the city as best they could, and then studied each ambulance run to see how it was working.

“I pretty much expected that we would find a patient every once in a while who deteriorated en route to a hospital that was farther away, but that it would be a very, very small number,” says Gary Merlotti, chairman of surgery at Mt. Sinai Hospital and one of the architects of the city’s trauma network. “I truly expected it would be somewhere in the range of five a year. We couldn’t even find that five.”

In fact he says he couldn't with certainty find even one. That came as a surprise to Merlotti and other trauma professionals, and it seems to fly in the face of the so-called “golden hour,” long a rule of thumb in trauma care. The idea is that if a patient gets definitive treatment within an hour, he or she is much more likely to live. But Chicago's experience, and in fact the most current national research, suggest that doesn't matter much.

“The best, largest study available to us now suggests that pre-hospital time isn't as related to injury death as we've always sort of assumed, and as our instincts would tell us it is,” says Brendon Carr, a physician and professor of emergency medicine at the University of Pennsylvania. “It brought some question to whether this idea of this golden hour is really true.”

That study came out last year, and is still reverberating in the medical field. It examined records for 3,656 trauma patients at 51 hospitals, and found, surprisingly, differences in transport times really don't affect survival. This may have to do with the quality of care people get in the ambulance on the way. The study went so far as to suggest ambulances may not always even need sirens and emergency lights during trauma runs.

Carr says the study is well designed and its findings robust, but the conclusion is so counterintuitive that he and other trauma professionals are still wrestling with it.

“It's hard for anybody who works in this space to not read that paper and think, ‘It makes sense to me statistically, it makes sense methodologically, but my gut tells me something different.’ My gut tells me that there is a small subset of folks, and we just didn't identify them correctly,” Carr says.

Some research out of Chicago has identified one subset of the population for whom transport times may make a difference. Dr. Marie Crandall of Northwestern University’s Feinberg School of Medicine has studied gunshot victims in Chicago, and found that transport times do affect their chances of survival. That research has not yet been peer-reviewed or published.

A study in the Southland

But if time really matters, one might expect losing a trauma center would mean worse outcomes. Recent history may offer a clue on that question, in the case of St. James Health in south suburban Olympia Fields. St. James ended its trauma care in 2008, leaving a large area of the south suburbs farther from a trauma center. Cook County commissioned a study to see if patients are doing worse in terms of mortality, medical complications, length of hospital stay and other outcomes.

“I ran it every which way but loose, you know?” says Lee Friedman of the University of Illinois at Chicago School of Public Health, who conducted the research.

“I tried considering all these different aspects in terms of conditions that can change, penetrating versus blunt, body organ affected, type of injury by body organ, in the end no indication of an increase in in-hospital mortality,” Friedman says.

So if taking a trauma center away didn't lead to more deaths, would adding a trauma center save lives? Some activists believe it would, and that’s why they’re calling for a trauma center on Chicago’s South Side. But the University of Pennsylvania’s Brendan Carr says any change would likely be minimal.

“Do I think that there are going to be stories where it had an impact? Yeah. Do I think that overall you could demonstrate that it has a giant impact? I think probably not. I mean, I think it's going to be a needle in the haystack,” Carr says.

That raises the question of how to balance the costs and benefits of a big investment like adding a new trauma center, and gets at a basic tension in public health policy: Do you plan based on what's best for an individual – someone's son or mother or brother – or do you focus on what's best for the whole population?

For Carr, one clearly must focus on the group, but the choice is not an easy one.

“I wear two hats. When I'm standing at the bedside of someone who's critically ill, I don't wear my population health hat,” Carr says. “These are expensive systems to build. So I feel conflicted when I attend meetings about how to spend public money to improve systems of care. Feeling conflicted is probably the right thing.”

An issue of equity?

It’s unclear how the disparity in transport times might affect outcomes. Even Craig Newgard, lead author of the large study that casts doubt on the “golden hour” thesis, says he doesn’t believe the question is fully answered. For Toussaint Losier, an activist working with the young people demanding a trauma center on the South Side, any doubt on these life-or-death issues is not acceptable.

“As much as we take heart from these findings and what the experts are saying, if there's ambiguity we should still dig further. We shouldn’t be comfortable with this question being unsettled,” Losier says.

Losier and the group he’s working with, Fearless Leading by the Youth, are pressuring the University of Chicago to reinstate the trauma center it discontinued more than two decades ago. Standing in the shadow of the Hyde Park hospital, he says the maps based on WBEZ's data don’t surprise him. The worst stretch of town starts right near here and runs south. And that, he says, suggests there are more than just outcomes at play here. There’s also a question of equity.

“The parts of the city where the question of a trauma center is coming from are those parts of the city that are considered marginal, on the periphery of not just the way the city's laid out, but of whose life is valued and whose life is not valued,” says Losier.

It’s not just activists who make that case. Trauma doctors steeped in the science raise similar points.

“People in these communities feel they don’t have the same police presence,” says James Doherty, trauma director at Advocate Christ Hospital in Oak Lawn, which serves much of the South Side. “They don’t have the same garbage pickup. It gets down to that level. And this is just an exacerbating factor of that – why don’t we have a trauma center? Now the realities are, a lot of these stem from the same socioeconomic factors.”

The best available research strongly indicates that people are not dying because it takes an extra 10 or even 20 minutes to get to a trauma center. But unequal access to trauma care tracks with other health disparities. WBEZ's numbers and the stories of doctors and patients show the inequalities are part of a broader picture of Chicago where one’s chances of living and thriving depend a lot on one’s ZIP code.

Corrections: This story has been updated to reflect Dr. Brendan Carr's proper title. He is a physician and professor of emergency medicine. The original audio post from this segment misidentified Lee Friedman's place of employment. Friedman is at the University of Illinois at Chicago School of Public Health.

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